Here are some of the highest-yield pearls related to the treatment of CAP!
Let me know what your favorite pearls are, and if you'd add anything!
- Thread -
Atypical bacteria need to be treated with something other than a beta-lactam because they either have absent or unique cell walls.
Azithromycin or doxycycline both inhibit bacterial protein synthesis.
Doxy can cause pill esophagits and sun-sensitivity.
Fluoroquinolones (but not so much azithromycin!) can prolong QT, be wary if on other prolonging meds.
Need to highlight this great @emcrit article!
emcrit.org/pulmcrit/myth-busting-azithromycin-does-not-cause-torsade-de-pointes-or-increase-mortality/
Ciprofloxacin is less effective than levofloxacin or moxifloxacin at treating pneumococcal respiratory infections and should be avoided in pneumonia.
The reason is that it has less gram-positive coverage (need to cover for strep pneumo!) and less lung penetration.
HFNC can help reduce work of breathing and stave off intubation in severe CAP.
It may be better than BIPAP since patients can tolerate it for longer and it allows for easier clearance of secretions.
In general, unless you are concerned about poor source control, resistance, or new infection, 7 days of antibiotics is likely sufficient to treat pneumonia even in severe CAP and in sick ICU patients with MRSA or pseudomonas.
Only give metronidazole or clindamycin if you are concerned about lung abscess or empyema because these represent non-oxygenated areas in or around the lung where anaerobes can grow.
Do not add anaerobic coverage for run of the mill aspiration pneumonia.
When covering for MRSA,
Daptomycin cannot be used for pneumonia since it is inactivated by surfactant
Linezolid can cause serotonin syndrome when given with other medications such as SSRIs and methadone
Parapneumonic effusions develop in the pleural space adjacent to a pneumonia.
They are seen in 20-57% of inpatients with pneumonia and 5-10% progress to empyema.
An empyema is purulence in the pleural space – these will always require drainage
It usually takes ~300cc of fluid for an effusion to be seen on CXR.
Effusions are “complicated” if the fluid has a positive gram stain (GS) or culture, or if the effusion is loculated.
In general, pleural effusions alone are rarely the cause of dyspnea or hypoxia unless it takes up > half of a hemithorax. If this is not the case, you should be thinking about other etiologies for a patient's symptoms.
If an effusion is large or loculated you will likely need to drain it via thoracentesis. Empyema may need a pigtail catheter to continuously drain.
If the patient does not improve with antibiotics or they keep getting recurrent pneumonia - think recurrent aspiration, underlying lung disease (COPD, bronchiectasis), post-obstructive (malignancy), immunodeficiency, or COP.
A CT may help clarify.